A pragmatic evaluation of the implementation and acceptance of a universal second trimester cervical length screening program in an un-selected population.

PURPOSE: To evaluate patients' acceptance of a universal transvaginal ultrasound cervical length (CL) screening program and the feasibility of initiating treatment with progesterone in a clinical setting in women found to have a short cervix. METHODS: An observational, pragmatic cohort study was conducted at one tertiary care facility from 2012-2015, involving eligible women with singleton pregnancies who accepted and underwent second-trimester CL screening. The primary outcomes were the percentage of women who were eligible and accepting of screening, compliance with progesterone treatment, and the screening value of TVCL in predicting SPTB. Secondary outcomes were the number of women who received progesterone treatment and the rates of SPTB. RESULTS: Overall cervical length screening acceptance rate was found to be 82.5%. Of the 797 women that underwent screening, 21 women (2.6%) had a TVCL < 25 mm, of whom nine had a TVCL < 20.0 mm. Nineteen of the 21 women with a TVCL < 25 mm were treated with progesterone, with a 94.7% compliance rate. Delivery outcomes were obtained for 767 women. Of those with a TVCL < 25 mm, there was a 35% rate of SPTB as opposed to a 6.3% SPTB rate in those with TVCL > 25 mm. The negative predictive value for SPTB with a TVCL 25 mm or greater was 94.0%. CONCLUSION: Universal cervical length screening was successfully implemented in 82.5% of the patient population with a high compliance rate with progesterone treatment. Furthermore, there was a higher rate of SPTB in those with a shorter cervix. Based on our outcomes obtained in an observational and pragmatic manner, we showed that incorporating second trimester transvaginal cervical length screening into routine clinical practice is readily accepted and, with the addition of vaginal progesterone treatment, may reduce the rate of prematurity.

Is mid-trimester cervical length screening effective for reduction of threatened preterm labor?

OBJECTIVE: To assess the incidence of threatened preterm labor and preterm labor admissions and treatment of women with singleton gestations and no prior preterm birth before and after implementation of the universal mid-trimester transvaginal ultrasound cervical length screening. MATERIALS AND METHODS: A retrospective cohort study included of singleton gestations without a history of preterm birth presenting with threatened preterm labor between 24 0/7 and 36 6/7 gestational week in two study periods: before and after the implementation of the universal cervical length screening. Women with cervical length <25 mm were considered being at high risk for preterm birth and were prescribed a treatment with vaginal progesterone daily. The primary outcome was the incidence of threatened preterm labor. Secondary outcomes were the incidence of preterm labor. RESULTS: We have found a significant increase in the incidence of threatened preterm labor from 6.42% (410/6378) in 2011 to 11.61% (483/4158) in 2018 (p < 0.0001). Gestational age at triage consult was lower in than in 2011, although the rate of admission for threatened preterm labor was similar in both periods. There was a significant decrease in the incidence of preterm delivery <37 weeks from 25.60% in 2011 to 15.94% in 2018 (p < 0.0004). Although there was a reduction in preterm delivery ≤34 weeks, this reduction was not significant. CONCLUSION: The universal mid-trimester cervical length screening in asymptomatic women is not associated with a reduction in the frequency of threatened preterm labor or the admission rate for preterm labor, but reduces the rate of preterm births.

Short cervix and preterm birth in the top end.

BACKGROUND: Reducing rates of preterm birth (PTB) remains a significant challenge. The Northern Territory (NT) records some of the highest rates of PTB in the country, especially in First Nations women. In 2014, a Western Australian (WA) preterm birth prevention initiative involved the implementation of seven key initiatives. One of these was routine mid-trimester cervical length measurement. The initiative successfully reduced PTB rates following its first year of implementation. This was the first successful reduction in PTB, including the earlier gestational ages, across a population. AIMS: To assess the uptake of routine cervical length measurement in the Top End of the NT after the success of the WA PTB prevention initiative and assess if treatment of a short cervix improved PTB rates. METHODS: A retrospective cohort study of all women who received antenatal care and delivered their baby at the NT's only tertiary hospital was performed. Mid-trimester ultrasound scan data were collected from two separate time windows, before and after the implementation of the WA intervention. Treatments and gestational age at birth were recorded. RESULTS: Adoption of routine screening of cervical length measurement at mid-trimester ultrasound in the NT was successful, increasing from 4 to 88%. Detection rates of short cervix doubled. However, there was no difference to PTB rates despite targeted management. CONCLUSION: PTB remains a significant challenge in the NT, especially for First Nations women who are found to have a short cervix more commonly than non-Indigenous women in the Top End.

Predictive factors for vaginal delivery by induction of labor in uncomplicated pregnancies at 40-41 gestational weeks: A Japanese prospective single-center cohort study.

AIM: We investigated cervical parameters predictive of vaginal delivery in elective labor induction among women at 40-41 gestational weeks. METHODS: This Japanese prospective single-center cohort study was conducted between July 2019 and June 2020. We enrolled women with an uncomplicated singleton pregnancy who underwent labor induction at 40-41 gestational weeks. We analyzed background characteristics and cervical parameters, including Bishop score, cervical length, posterior cervical angle, and changes in cervical parameters before and after cervical dilatation. The endpoint was the rate of vaginal delivery. RESULTS: Of 142 eligible participants, all 24 multiparous women underwent vaginal delivery. Among the nulliparous women (n = 118), the following categories showed significantly higher rates of vaginal delivery: Bishop scores of ≥6 before and after dilatation, compared with Bishop score <6 (adjusted prevalence ratio (aPR) [95% confidence interval (CI)]; 1.58 [1.17-2.13] and 1.56 [1.13-2.14], respectively) and cervical length of <10 and 10-20 mm before dilation, compared with cervical length of >30 mm (aPR [95% CI]; 1.47 [1.00-2.15] and 2.13 [1.42-3.18], respectively). The posterior cervical angle and other background characteristics showed no significant associations. Furthermore, women with cervical lengths of ≥20 mm before and <20 mm after dilatation showed a higher rate of vaginal delivery, compared to cervical length of ≥20 mm even after dilatation (aPR [95% CI]; 1.95 [1.19-3.20]). CONCLUSIONS: High Bishop score, short cervical length, and changes in cervical length with dilatation are potential independent predictors of vaginal delivery following elective labor induction in nulliparous women at 40-41 gestational weeks.

The introduction of a universal transvaginal cervical length screening program is associated with a reduced preterm birth rate.

BACKGROUND: Midtrimester sonographic short cervix is a good predictor of preterm birth in singleton pregnancies. OBJECTIVE: This study aimed to assess the impact of implementing a universal transvaginal cervical length screening program on preterm birth rate. STUDY DESIGN: This study consisted of 2 parts: a before-and-after multicenter study and a study on the ECHOCOL ("echo"="ultrasound" and "col"="cervix" in French) prospective cohort. We compared the rate of preterm birth before and after the introduction of universal cervical length screening at the time of midtrimester anatomy ultrasound. The multicenter before-and-after regional study included all women with a singleton pregnancy who gave birth after 24 weeks' gestation in the South East of France from January 1, 2012 to April 30, 2018. In parallel, the ECHOCOL cohort study was prospectively conducted from May 2015 to July 2018, including 17 maternity hospitals in the South East region of France. In case of asymptomatic short cervix <25 mm, treatments offered included 200 mg of vaginal progesterone, or cerclage, or a pessary until 34 weeks' gestation. RESULTS: We observed a significant decrease rate of preterm birth between periods A and B after multivariate analysis. (respectively, 5.8% vs 5.6%; adjusted odds ratio, 0.92; 95% confidence interval, 0.89-0.95; P<.0001). In parallel, the percentage of cervical length screening significantly increased from 28.9% in period A to 52.9% in period B (odds ratio, 2.76; 95% confidence interval, 2.71-2.80; P<.0001). Among the 3468 patients of the ECHOCOL prospective cohort, 38 (1.1%) asymptomatic short cervices were detected, and 192 patients gave birth prematurely (11 with an asymptomatic short cervix and 181 without). In the ECHOCOL cohort, a marked but statistically insignificant tendency toward a reduced rate of preterm birth before 37 weeks of gestation was observed (from 5.8% to 5.5%; adjusted odds ratio, 0.72; 95% confidence interval, 0.51-1.03; P=.068). CONCLUSION: This study showed a significantly lower rate of preterm birth after the implementation of a universal cervical length screening and treating policy during the second trimester of pregnancy. The clinical trial was registered under NCT02598323.

Prediction of Preterm Delivery among Low-risk Indian Pregnant Women: Discriminatory Power of Cervical Length, Serum Ferritin, and Serum Alpha-fetoprotein.

Background: Around 80% of preterm births (PTBs) occur spontaneously. Various biomarkers are being evaluated to assess the possible role of chorioamniotic inflammation in PTBs. Aim: The aim of this study was to establish the accuracy of serum bio-markers( cut off values of ferritin and alpha-fetoprotein [AFP] at midtrimester) along with cervical length [CL] assessment to predict preterm delivery among low-risk women. Methods: Three hundred low-risk pregnant women attending the antenatal clinic of a tertiary health care facility were included and underwent CL measurement during mid-trimester by transvaginal ultrasonography and their serum levels of ferritin and AFP were recorded. All were followed up till delivery. Results: Receptor-operated characteristic curves for ferritin, AFP, and CL were constructed. Area under curves and Youden Index calculated for each marker were very low (<0.5) which is statistically considered very poor for a screening test. Conclusion: Serum ferritin and AFP together with CL measurement in the second trimester of pregnancy had poor discriminatory value in predicting preterm delivery among low-risk asymptomatic pregnant women.

The Use of Mid-Pregnancy Cervical Length to Predict Preterm Birth in Brazilian Asymptomatic Twin Gestations / O uso da medida do colo uterino no segundo trimestre de gestantes brasileiras como preditor de prematuridade na gestação gemelar

Abstract Objective To describe a reference curve for cervical length (CL) in mid-trimester twin gestations using transvaginal ultrasound (TVU) and to investigate whether short CL increases spontaneous preterm birth (sPTB) in asymptomatic twin pregnancies. Methods This was a prospective cohort study performed at 17 outpatient antenatal facilities of Brazil with women at 18 0/7 to 22 6/7 weeks of gestation who participated in a randomized clinical trial screening phase (P5 trial) between July 2015 and March 2019. TVU was performed to provide CL measurement in all screened women. Almost all women with CL ≤ 30 mm received vaginal progesterone 200mg/day and they were also randomized to receive cervical pessary or not. We considered data from the CL distribution among asymptomatic twin pregnancies and analyzed CL and its association with PTB generating receiver operating characteristics (ROC) curves and Kaplan-Meier curves. Results A total of 253 pregnant women with twins were included in the distribution curve. The mean CL was 33.7 mm and median was 35.5mm. The 10th percentile was 17.8mm. We identified a PTB rate of 73.9% (187/253) with 33.6% of sPTB < 37 (85/253) and 15% (38/253) of sPTB < 34 weeks. The best cutoff point to predict sPTB < 37 was 24.15 mm. However, the ROC curve showed a poor performance (0.64). The Kaplan-Meier survival curves identified that only CL values ≤ 20mm were associated to sPTB < 34 weeks. Conclusion A cutoff point of CL ≤ 20 mm can be interesting point to identify short cervix in Brazilian twin pregnancies. However, in Brazilian asymptomatic twin pregnancies, CL does not show a good performance to predict PTB.

Resumo Objetivo Descrever uma curva de referência da medida do colo uterino no Segundo trimestre de gestações gemelares através de ultrassonografia transvaginal (TVU) e investigar a correlação entre a medida do colo uterino (CL) e o parto prematuro espontâneo (sPTB) em pacientes assintomáticas. Métodos Foi realizado uma coorte prospectiva multicêntrica em 17 centros de referência do Brasil com mulheres com gestação gemelar entre 18 0/7 a 22 6/7 semanas de gestação que participaram da primeira fase de um ensaio clínico randomizado (P5 trial) entre Julho/2015 a Março/2019. TVU foi realizada para obter a medida do colo uterino em todas as mulheres. A maioria das mulheres com CL ≤30 mm receberam progesterona por via vaginal 200mg/dia e estas foram randomizadas para receber ou não um pessário cervical. Este estudo considerou dados da medida do colo uterino entre mulheres assintomáticas, desenvolvendo uma curva de referência para gestantes gemelares e sua capacidade de predição do parto prematuro através de curva ROC (receiver operating characteristics) e curvas de sobrevida de Kaplan-Meyer. Resultados O total de 253 gestantes foram incluídos no estudo, A média do CL foi 33.7mm e a mediana 35.5mm. O Percentil 10 do CL foi 17.8mm. A taxa de parto prematuro foi de 73.9% (187/253) com 33.6% de sPTB < 37 (85/253) e 15% (38/253) de sPTB < 34 semanas. O melhor ponto de corte para predizer sPTB < 37 foi 24.15 mm, entretanto a curva ROC demonstrou baixa performance (0.64). A curva de Kaplan-Meier para sPTB identificou que apenas CL ≤ 20 mm estavam associados a sPTB < 34 semanas. Conclusão Colo uterino ≤20 mm pode ser um interessante ponto de corte para identificar colo curto entre gestações gemelares assintomáticas brasileiras. Entretanto, a medida do colo uterino não apresentou boa performance para predizer parto prematuro.

Transabdominal and transvaginal ultrasound assessment of cervical length - can transvaginal approach be avoided?

OBJECTIVES: This study aimed to compare transabdominal (TA) and transvaginal (TV) ultrasound assessment of cervical length during pregnancy and to establish cervical length above which transvaginal measurement is not necessary. MATERIAL AND METHODS: Cervical length was measured using TA and TV method in the first (11 + 0-13 + 6 weeks), the second (20 + 0-21 + 6 weeks) and the third trimester (28 + 0-31 + 6 weeks) in 250 women with singleton pregnancy and low risk for preterm birth. RESULTS: If the cervical length measured in the second trimester of pregnancy with transabdominal approach is ≥ 28.5 mm and ≥ 30.5 mm in the third trimester, it can be assumed with 100% sensitivity the cervical length measured with transvaginal method will be > 25 mm. Transabdominal cervical length measurement in the second and third trimester allows 89% and 65% of patients, respectively, to avoid transvaginal scan. CONCLUSIONS: Second and third trimester screening by transabdominal cervical length measurements in a group of pregnant women with low risk for preterm birth is useful to determine which patients require transvaginal measurement.

Frequency of cerclage in consecutive pregnancies of women with history of preterm birth.

BACKGROUND: Serial cervical length screening is performed in women with a history of preterm birth to determine indication for cerclage placement. Our aim is to evaluate the frequency of cerclage placement in consecutive pregnancies with preterm birth history to determine whether performing serial cervical length screening for women with a history of late (34-36 6/7 weeks) spontaneous preterm birth (SPTB) should be reconsidered. METHODS: Retrospective evaluation of cerclage frequency and gestational age of delivery for consecutive singleton births for 69,671 women whose first birth was a SPTB. RESULTS: History of late SPTB was associated with a lower frequency of cerclage than history of early SPTB (0.83% vs 4.88%, OR 0.16, 95% CI 0.14-0.18). Rates of recurrent SPTB were lower for women with history of late SPTB than those with history of early SPTB (13.45%, 3.74% early, 9.71% late vs 20.69%, 9.12% early, 11.57% late). CONCLUSION: Women with a history of late PTB have a lower risk of recurrent PTB than those with a history of early PTB but constitute most of those undergoing serial cervical length screening for potential cerclage placement. Practice guidelines for screening women with a history of late PTB should be re-evaluated.

Nomogram Incorporating Multimodal Transvaginal Ultrasound Assessment at 20 to 24 Weeks' Gestation for Predicting Spontaneous Preterm Delivery in Low-Risk Women.

Background: The majority of women who experience spontaneous preterm delivery (SPTD) have low-risk, asymptomatic pregnancies with a cervical length (CL) ≥25mm and no clear risk factors. Despite the fact that cervical elastography is a potential tool for predicting SPTD, there is currently no feasible solution to make a reliable prediction for preventing SPTD. Objective: The aim of this study was to construct a nomogram including multimodal transvaginal ultrasound parameters during the second trimester to predict SPTD in low-risk women. Methods: This multi-center study enrolled 1260 women with singleton pregnancies between 20 and 24 weeks' gestation. CL and cervical elastography data were obtained when they were undergoing the second-trimester anomaly scan. Univariate and multivariate Logistic regression were utilized to screen predictors independently related to SPTD from the maternal characteristics and multimodal ultrasound data. Then construct a nomogram to determine the likelihood of SPTD in pregnant women. Results: A total of 66 pregnancies in the training cohort (7.8%, 66/842) and 37 pregnancies (8.9%, 37/418) in the validation cohort ended in SPTD. Age, uterine curettage, CL, and strain in the anterior lip of internal os were the independent predictors of SPTD (P < 0.001, < 0.001, = 0.007, and < 0.001, respectively). These predictors constituted a nomogram to predict the probability of SPTD for a pregnant woman in her second trimester. It showed good discrimination (C-index = 0.898 and 0.839), calibration (P = 0.258 and 0.115), and yielded net benefits both in the training and validation cohorts. Conclusion: The nomogram including data of multimodal transvaginal ultrasound at 20 to 24 weeks' gestation is expected to identify women with SPTD in the low-risk, asymptomatic population.

Lactobacilluscrispatus dominance in the vaginalmicrobiome reduces the occurrence of spontaneouspreterm birth in women with a short cervical length / Dominância de Lactobacillus crispatus no microbioma vaginal reduz a ocorrênciade parto prematuro espontâneo em mulheres com encurtamento do colo uterino

Introduction: The majority of pregnant women with a short cervix will deliver at term and, thus, may unnecessarily receive advanced monitoring and treatment. It is still necessary to define more accurately which sub-population of women with a short cervix is at elevated risk for early delivery. Objective: To determine if vaginal microbiome composition influenced the rate of spontaneous preterm birth in women with a short cervical length. Methods: In an exploratory, observational prospective study, vaginal secretions were obtained from 591 women at 21­24 week gestation. Vaginal microbiome composition was determined by analyzing the V1­V3 region of the bacterial 16S ribosomal RNA gene. Results: Lactobacillus crispatus was numerically dominant in the vagina in 41.7% of subjects, followed by L. iners in 32% and Gardnerella vaginalis in 12%. In women whose cervix was ≤25mm, the sensitivity to predict an spontaneous preterm birth was 11.8%. However, when L. crispatus was not the dominant vaginal bacterium, this sensitivity increased to 81.8%. Similarly, in women with a cervical length ≤30mm, the sensitivity to predict an spontaneous preterm birth increased from 21.7 to 78.3% when L. crispatus was not the dominant vaginal bacterium.In women with a prior spontaneous preterm birth and a cervix ≤25 or ≤30mm, L. crispatus dominance was also associated with a reduced rate of spontaneous preterm birth in the current pregnancy (p<0.001). Conclusion: In pregnant women with a cervix ≤25mm or ≤30mm, the risk for an spontaneous preterm birth is increased if L. crispatus is not dominant in the vagina.

Introdução: A maioria das mulheres grávidas com colo do útero curto dará à luz a termo e, portanto, pode receber desnecessariamente monitoramento e tratamento avançados. Permanece a necessidade de definir com mais precisão qual subpopulação de mulheres com colo do útero curto está em risco elevado de parto prematuro. Objetivo: Determinar se a composição do microbioma vaginal influenciou a taxa de parto prematuro espontâneo em mulheres com colo curto. Métodos: Em um estudo prospectivo exploratório observacional, os conteúdos vaginais foram obtidos de 591 mulheres com 21­24 semanas de gestação. A composição do microbioma vaginal foi determinada pela análise da região V1­V3 do gene de RNA ribossômico bacteriano 16S. Resultados: Lactobacilluscrispatus foi numericamente dominante na vagina em 41,7% dos indivíduos, seguido por L. iners em 32% e Gardnerella vaginalis em 12%. Em mulheres cujo colo do útero era <25 mm, a sensibilidade para prever uma taxa de parto prematuro espontâneo foi de 11,8%. No entanto, quando L. crispatus não era a bactéria vaginal dominante, essa sensibilidade aumentou para 81,8%. Da mesma forma, em mulheres com comprimento cervical <30 mm, a sensibilidade para prever uma taxa de parto prematuro espontâneo aumentou de 21,7 para 78,3% quando L. crispatus não era a bactéria vaginal dominante. Em mulheres com taxa de parto prematuro espontâneo anterior e colo do útero <25 ou <30 mm, a dominância de L. crispatus também foi associada a uma taxa reduzida de taxa de parto prematuro espontâneo na gravidez atual (p<0,001). Conclusão: Em mulheres grávidas com colo do útero <25 ou <30 mm, o risco de parto prematuro espontâneo é aumentado se L. crispatus não for dominante na vagina.

Twin pregnancies: can sonographic measurements and changes in cervical length during pregnancy predict preterm birth?

OBJECTIVE: This study measured cervical length (CL) at 14-16 and 21-24 weeks of gestation and assessed whether the difference between measurements is predictive of preterm birth (PTB) among asymptomatic women with twin gestations. METHOD: This retrospective, cohort study included patients with two consecutive CL measurements with transvaginal sonography at 14-16 weeks of gestation (CL1) and 21-24 weeks (CL2). PTB was defined as delivery prior to 37 + 0 weeks of gestation. Electronic medical records were reviewed for demographic, medical and delivery data. CL1, CL2 and the change between scans were evaluated and correlated with the prediction of PTB. RESULTS: Among 103 women with twin gestations, 76 (73.7%) delivered at term and 27 (26.3%) had PTB. CL1 and CL2 were not good predictors of PTB (p = .32 and p = .38, respectively). The correlation between CL change and PTB was not significant (p = .08). The correlation between CL change and delivery after 38 weeks was not significant (p = .3). Baseline characteristics and perinatal outcomes between term and preterm deliveries were similar. CONCLUSIONS: The delta between routine cervical length measurements at 14-16 and 21-24 weeks of twin gestations cannot be used as a reliable predictor of PTB.

Can sonographic changes in cervical length during pregnancy predict the need for cervical ripening in term pregnancies?

PURPOSE: To evaluate the effect of changes in sonographic cervical length (CL) measured at 14-16 and 21-24 weeks of gestation, on cervical ripening in term pregnancies. METHODS: This retrospective, cohort study included term pregnancies with CL measured with transvaginal sonography (CL1 at 14-16 weeks gestation and CL2 at 21-24 weeks). History of preterm labor, multiple gestations, planned caesarean section, fetal anomalies and stillbirths were excluded. Participants were grouped based on ≥ 10% vs. < 10% CL shortening between measurements. The primary outcome was whether cervical shortening < 10% between CL1 and CL2 was associated with increased use of cervical ripening. Secondary outcomes were gestational age at delivery, delivery mode and birthweight. RESULTS: Among 267 women who met the inclusion criteria, CL decreased ≥ 10% between scans in 70 (26.3%) and < 10% in 197 (73.7%). Baseline characteristics were similar between groups. Fewer women with ≥ 10% shortening between scans, underwent cervical ripening (7.1% vs. 16.8%, p < 0.05). In addition, in the ≥ 10% group, although CL2 was in the normal range, it was shorter than in the < 10% group (34.3 ± 6.7 mm vs. 40.1 ± 6.4 mm, p < 0.01). CONCLUSION: Decrease in cervical length > 10% between 14-16 and 21-24-weeks' gestation is associated with lower use of cervical ripening at term.

Predictive value of transvaginal ultrasound measurement of cervical length in first and second trimester on spontaneous preterm birth in singleton pregnancies / 中华围产医学杂志

Objective:To explore the predictive value of transvaginal ultrasound measurement of cervical length (CL) in the first and second trimester on spontaneous preterm birth in singleton pregnant women.Methods:This study retrospectively recruited 2 254 singleton pregnancies without severe comorbidities at Peking University First Hospital from January 2019 to June 2019. CL was measured for all subjects using transvaginal ultrasound in the first (11-13 +6 weeks) and second trimester (21-23 +6 weeks). Differences in CL between women with preterm (preterm group) and full-term delivery (full-term group) as well as the CL during the first and second trimester were compared. The independent risk factors for preterm birth and the predictive value of CL in the first and second trimester for spontaneous preterm birth were also explored. Fisher's exact test, t-test, χ2 test, and logistic regression analysis, etc, were adopted for statistical analysis. Results:(1) For the 2 254 subjects, CL measured in the first trimester and second trimester were (36.1±4.2) mm (22.4-52.6 mm) and (36.9±5.3) mm (2.9-59.7 mm), respectively. The incidence of short cervix in the first trimester and second trimester were 0.31% (7/2 254) and 1.46% (33/2 254), respectively. When CL was ≤25.0 mm ( OR=43.92, 95% CI:6.83-282.49) or >25.0-≤30.3 mm ( OR=6.59, 95% CI:1.97-22.0) in the first trimester, the risk of short cervix increased in the second trimester (both P<0.05). (2) The total incidence of preterm delivery was 3.06% (69/2 254). CL and the incidence of short cervix did not differ significantly in the first trimester between the preterm and full-term group [(35.2±4.5) and (36.1±4.1) mm, t=－1.78, P=0.076; 1.5% (1/69) and 0.3% (6/2 185), χ 2=2.98, P=0.084]. Compared with the full-term group, CL was shorter and the incidence of short cervix was higher in the second trimester in the preterm group [(33.6±6.7) vs (37.0±5.2) mm, t=－5.12;8.7% (6/69) vs 1.2% (27/2 185), χ 2=25.80, P<0.001]. (3) Multivariate regression analysis showed that age ≥35 years ( OR=2.05, 95% CI:1.22-3.46), history of spontaneous preterm birth ( OR=25.25, 95% CI:5.01-127.28), conception assisted by reproductive technology ( OR=10.39, 95% CI:2.39-50.33), and short cervix during the second trimester were independent risk factors for premature delivery. (4) There was no significant difference in the risk of preterm delivery when comparing to those with CL≤25.0 mm, >25.0-≤30.3 mm, >30.3-≤33.0 mm, >33.0-≤35.7 mm, >35.7-≤38.7 mm women with CL>38.7 mm during the first trimester (all P>0.05). The risk of premature delivery was relatively increased for those with CL≤25.0 mm,>25.0-≤29.5 mm, >29.5-≤33.6 mm, >33.6~≤36.8 mm, >36.8~≤40.1 mm during the second trimester compared to those with CL>40.1 mm [ OR (95% CI):17.64 (4.99-62.32), 6.89 (2.11-22.55), 3.58 (1.34-9.59), 4.04 (1.58-10.32), 3.34 (1.28-8.67), respectively , all P<0.05]. (5) When CL≤25.0 mm and ≤29.5 mm in the second trimester were used as the cut-off value, the prediction of preterm delivery was with a sensitivity of 8.70% and 17.39%, specificity of 98.80% and 95.29%, positive predictive value of 18.20% and 10.43%, negative predictive value of 97.16% and 97.34%, and the accuracy rate of 96.01% and 92.90%, respectively. Conclusions:There were no significant differences in CL and the incidence of short cervix during the first trimester among women with preterm or full-term delivery. CL in the first trimester is not an independent risk factor for preterm birth, but the risk of short cervix in the second trimester is increased when CL≤30.3 mm in the first trimester. The shorter the cervix during the second trimester, the greater the risk of preterm birth.

Minireview: Utilidad de las pruebas predictivas para parto pretérmino utilizadas en la práctica clínica / Minireview: Utility of predictive tests for preterm birth used in clinical practice

El parto prematuro, definido como el parto que ocurre antes de las 37 semanas de gestación, es una condición obstétrica grave que representa el 11% de los embarazos en todo el mundo. Las pruebas predictivas para parto prematuro son importantes, dado el impacto personal, económico y de salud del parto prematuro. Esta revisión explora la utilidad tanto de las pruebas predictivas actuales utilizadas en la práctica clínica (características maternas, longitud cervical y marcadores bioquímicos), así como nuevas pruebas emergentes. Se realizó una búsqueda electrónica en las bases de datos científicas en salud: PUBMED, COCHRANE, SCIELO, revisión de repositorios virtuales de universidades nacionales utilizando los siguientes ítems de búsqueda y sus combinaciones: parto pretérmino, longitud cervical, acortamiento cervical, cervicometría, fibronectina fetal, factores de riesgo, características maternas. Se incluyeron trabajos publicados en inglés y español, desde el año 2006 hasta el año 2020, que respondían al objetivo de la revisión: La utilidad de los diferentes predictores para parto pretérmino. En total se incluyeron 30 artículos en la presente revisión bibliográfica. Existen múltiples criterios científicos sobres las diferentes técnicas actuales para identificar pacientes de riesgo y lograr una prevención adecuada del parto pretérmino. La medición de la longitud cervical por ecografía transvaginal es el método más rentable en mujeres con historia de parto prematuro o síntomas de amenaza de parto prematuro; la evidencia actual permite sostener que también es indispensable realizar cervicometría de rutina a todas las pacientes, aún de bajo riesgo. Existen métodos ecográficos de predicción como la elastografía cervical y el índice de consistencia cervical que son prometedores, pero existen limitaciones en su implementación técnica y se propone que podrían ser una posible alternativa en el futuro, que puede combinarse con la longitud cervical. También, la adición de la medición de la longitud cervical a las pruebas bioquímicas parece mejorar la precisión predictiva(au)

Preterm labor, defined as delivery before 37 weeks of gestation, is a serious obstetric condition that accounts for 11% of pregnancies worldwide. Predictive tests for preterm birth are important, given the personal, economic, and health impact of preterm birth. This review explores the utility of both, the current predictive tests used in clinical practice (maternal characteristics, cervical length and biochemical markers), as well as the new emerging tests. An electronic search was carried out in the scientific health databases: PUBMED, COCHRANE, SCIELO, national universities virtual repositories were also reviewed, using the following search items and their combinations: preterm delivery, cervical length, cervical shortening, cervicometry, fetal fibronectin, risk factors, and maternal characteristics. We included papers in English and Spanish published from 2006 to 2020, which responded to the aim of the review: the utility of predictive test for preterm delivery. A total of 30 articles were included in this review. There are multiple scientific criteria on the different current techniques to identify patients at risk and achieve adequate prevention of preterm birth. Measurement of cervical length by transvaginal ultrasound is the most cost-effective method in women with a history of preterm labor or symptoms of preterm labor; the current evidence allows us to affirm that it is also essential to perform routine cervicometry in all patients, even with low risk. There are promising ultrasound predictive methods such as cervical elastography and cervical consistency index, but there are limitations in their technical implementation, it is proposed that they could be a possible alternative in the future, that can be combined with cervical length measurement. Also, adding cervical length easurement to biochemical tests appears to improve predictive accuracy.(au)

Review of tumor infiltrating lymphocytes assessment in breast cancer in routine diagnostic practice.

Evaluation of tumor infiltrating lymphocytes (TIL) is gaining importance in many cancers not only because of their prognostic, but also predictive significance. One of the tumors in which the evaluation of TIL is of prognostic importance and has potential predictive impact on the modification of treatment procedures is breast cancer, especially its so-called triple negative, and HER2 positive variants.The aim of this review is to provide an overview of the issue of TIL evaluation in breast cancer, focusing not only on the clinical significance of this evaluation, but especially on the methodological aspects of evaluation and standardized reporting of the results.

Effect of second-trimester sonographic cervical length on the risk of spontaneous preterm delivery in different risk groups: A prospective observational multicenter study.

INTRODUCTION: The aim of the study is to compare the effect of cervical length measured with transvaginal ultrasound in the second trimester on the risk of spontaneous preterm delivery (PTD) between different risk groups of asymptomatic women with a singleton pregnancy. MATERIAL AND METHODS: This is a pre-planned exploratory analysis of the CERVIX study, a prospective blinded multicenter diagnostic accuracy study. Asymptomatic women with a singleton pregnancy were consecutively recruited at their second-trimester routine ultrasound examination at seven Swedish ultrasound centers. Cervical length was measured with transvaginal ultrasound at 18-20 weeks (Cx1; n = 11 072) and 21-23 weeks (Cx2, optional; n = 6288). The effect of cervical length on the risk of spontaneous PTD and its discriminative ability was compared between women with: (i) previous spontaneous PTD, late miscarriage or cervical conization (high-risk group; n = 1045); (ii) nulliparae without risk factors (n = 5173); (iii) parae without risk factors (n = 4740). Women with previous indicated PTD were excluded (n = 114). Main outcome measures were: effect of cervical length on the risk of spontaneous PTD expressed as odds ratio per 5-mm decrease in cervical length with interaction analysis using logistic regression to test whether the effect differed between groups, area under the receiver operating characteristic curve (AUC), sensitivity, specificity, number needed to screen to detect one spontaneous PTD. RESULTS: The effect of cervical length at Cx2 on the risk of spontaneous PTD <33 weeks was similar in all groups (odds ratios 2.26-2.58, interaction p value 0.91). The discriminative ability at Cx2 was superior to that at Cx1 and was similar in all groups (AUC 0.69-0.76). Cervical length ≤25 mm at Cx2 identified 57% of spontaneous preterm deliveries <33 weeks in the high-risk group with number needed to screen 161. The number needed to screen for groups (ii) and (iii) were 1018 and 843. CONCLUSIONS: The effect of cervical length at 21-23 weeks on the risk of spontaneous PTD <33 weeks is similar in high- and low-risk pregnancies. The differences in number needed to screen should be considered before implementing a screening program.

Relationship between metalloproteinase-2 and -9 levels in plasma and vaginal secretion with preterm birth.

OBJECTIVE: To study the association of plasma and vaginal levels of matrix metalloproteinases 2 (MMP-2) and 9 (MMP-9), determined between 20+0 and 25+6 weeks of gestation, with preterm birth and its predictive value. STUDY DESIGN: All 129 cases of preterm birth (cases) and 258 randomly selected term patients (control group) were included in a cohort study with a nested case-control design. Inclusion criteria were living in Ribeirão Preto, Brazil, and gestational age 20+0 to 25+6 at enrollment. Exclusion criteria were multiple fetuses, congenital malformations or chromosome syndromes, and loss to follow-up. Maternal age, parity, smoking, and previous preterm birth were included as covariates. A blood sample and vaginal secretion were obtained for the determination of MMP-2 and MMP-9; the patients were screened for urinary tract infection and bacterial vaginosis, and cervical length was measured by ultrasound. The cut-off values for matrix metalloproteinases were calculated using receiver operating characteristic (ROC) curves for logistic regression analysis (crude and adjusted odds ratios). RESULTS: According to the WHO, in this study, preterm subtypes included 3.8 % extremely preterm, 6.9 % very preterm, and 89.2 % late preterm births. The plasma MMP-9 cut-off was 63.25 ng/mL and the area under the ROC curve was 0.725 (standard error 0.03; 95 % confidence interval, 0.677-0.769). The cut-off for plasma MMP-2 was 239.4 ng/mL and the area under the ROC curve was 0.585 (standard error 0.03, 95 % confidence interval, 0.521-0.649). Crude odds ratios showed an increased risk of preterm birth associated with plasma MMP-2 (odds ratio, 1.75; 95 % confidence interval, 1.14-2.68) and plasma MMP-9 (odds ratio, 3.26, 95 % confidence interval, 2.09-5.07); no association was detected for vaginal MMP-2 or 9. For plasma, adjusted odds ratios were 1.42 (95 % confidence interval, 0.80-2.53) for MMP-2 and 2.71 (95 % confidence interval, 1 .52-4.83) for MMP-9, along with an increased risk in other covariates. CONCLUSION: Elevated plasma MMP-9 levels and decreased MMP-2 levels were positively associated with preterm birth. Plasma MMP-9 level increased nearly three times the preterm risk.

Accuracy of the combination of commercially available biomarkers and cervical length measurement to predict preterm birth in symptomatic women: A systematic review.

An accurate prognostic method for preterm birth (PTB) could avoid unnecessary treatment(s) with potentially negative effects. The objective was to explore the prognostic accuracy of commercially available bedside cervicovaginal biomarker tests in combination with cervical length (CL) compared to CL measurement alone and/or a biomarker test alone, for PTB within 7 days after testing symptomatic women at 22-34 weeks. The MEDLINE, Cochrane, Embase and Web of Science databases were searched from inception to August 28th, 2019. Seven hundred and eight articles were identified and screened using Rayyan. Studies reporting on the predictive accuracy of combined tests compared to CL or biomarker alone for the prediction of PTB within 7 days of testing in symptomatic women with intact membranes were included. A piloted data extraction form was used. Direct comparisons of the prognostic accuracy of the combination test with CL measurement or a biomarker alone were done, as well as comparisons of prognostic accuracy of the included combination tests (indirect comparisons). Twelve articles were included (seven on fetal fibronectin, four on phosphorylated insulin-like growth factor binding protein-1, one comparing both). A variety of CL cut-offs was reported. The results could not demonstrate superiority of a combination method compared to single methods. Due to data scarcity and quality, the superiority of either predictive test for PTB, either combination or single, cannot be demonstrated with this systematic review. We recommend further research to compare available biomarkers.

Hegde's Modification of Fothergill Surgery for Cervical Elongation: A 7-Year Retrospective Review.

OBJECTIVE: This study aimed to evaluate the efficacy of Hegde's modification of Fothergill surgery, an innovative procedure for cervical elongation (CE), and to report perioperative challenges and follow-up. METHODS: This is a retrospective review of data from 12 patients who underwent successful repair of CE by Hegde's modification of Fothergill surgery from June 2012 to May 2019. Primary outcomes were cervical viability and stenosis. Secondary outcomes were perioperative complications, Pelvic Organ Prolapse Quantification system (POP-Q) measurement and staging, recurrence, conception rates, and World Health Organization Quality of Life (QOL) BREF (WHOQOL-BREF) scores. RESULTS: All women had a viable, patent cervix at 1-month follow-up. Perioperative complications included total intraoperative blood loss (>50 mL) and febrile morbidity (both 16.7%) and urinary tract infections (8.3%). The mean reduction of point C was 5.78 cm (2.87 ± 0.13 cm to -2.91 ± 1.55 cm). Recurrence was noted in 1 patient (8.3%) who had POP-Q stage 2 prolapse at 6 and 12 months of follow-up. The conception rate was 8.3% at 12 months. All women conceived spontaneously. Mean preoperative WHOQOL-BREF scores improved in all 4 domains, with major improvement seen in the physical domain, from 24.66 ± 8.18 to 70.91 ± 11.01, 19.0 ± 6.48 to 54.92 ± 8.21, 9.33 ± 7.46 to 59.33 ± 14.33, and 19.0 ± 4.89 to 47.07 ± 7.14, for the physical, psychological, social, and environmental domains, respectively. CONCLUSION: Hegde's modification of Fothergill surgery can be considered as a surgical option for the repair of isolated CE with a healthy cervix in women who desire uterine preservation with the major advantage of preventing cervical stenosis.